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General NPI Number Information
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NPI Number | 1053541409
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Entity Type | Organization
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Legal Business Name | PAULA S PRACTICE
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Dates
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Enumeration Date | 07/20/2009
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Last Update Date | 12/22/2009
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Provider Practice Location Address
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Address Line | 348 STATE ROAD 4
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City | SAN YSIDRO
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State | NM
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Zip | 87053-0348
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Country | US
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Telephone | 505-321-9935
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Fax | 575-289-2688
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Provider Business Mailing Address
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Address Line | PO BOX 1629
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City | CUBA
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State | NM
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Zip | 87013-1629
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Country | US
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Telephone | 505-321-9935
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Fax | 575-289-2688
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Authorized Official
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Title or Position | C0-DIRECTOR
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Name | MS. PAULA M ENYEART
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Credential | CFNP
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Telephone | 505-321-9935
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | R31220
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License Number State | NM
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